2012-13 ITR-1, PAGE 1

ITR-1 SAHAJ INDIAN INDIVIDUAL INCOME TAX RETURN AY 2012-13

A1 FIRST NAME A2 MIDDLE NAME

A3 LAST NAME A4 PERMANENT ACCOUNT NUMBER

A5 SEX A6 DATE OF BIRTH A7 INCOME TAX WARD/CIRCLE

; Male ; Female D D MM Y Y Y Y
A8 FLAT/DOOR/BUILDING A9 ROAD/STREET

A10 AREA/LOCALITY A11 TOWN/CITY/DISTRICT

A12 STATE A13 PINCODE

A14 EMAIL ADDRESS

A15 RESIDENTIAL/OFFICE PHONE NO. WITH STD CODE A16 MOBILE NO.
A17 Fill only one if you belong to 9 ; Government 9 ; PSU 9 ; Others
A18 Fill only one 9 ; Tax Refundable 9 ; Tax Payable 9 ; Nil Tax Balance A19 Fill only one 9 ; Resident 9 ; Non Resident 9 ; Resident but not ordinarily resident
A20 Fill only one: filed 9 ; Before due date-139(1) 9 ; After due date-139(4) 9 ; Revised Return-139(5) OR in response to notice 9 ; 142(1) 9 ; 148 9 ; 153A/153C

A21 If revised and D D MM Y Y Y Y

Receipt Number of Original Return Date of Filing Original Return

PART B - GROSS TOTAL INCOME Whole-Rupee(`) only.

B1 Income from Salary/Pension B1
NOTEð Ensure to fill “Sch TDS1” given in Page 2 7 If showing loss, mark the negative sign in bracket at left

B2 Income from One House Property B2 (-)

B3 Income from other sources B3 (-)
NOTEð Ensure to fill “Sch TDS2” given in Page 2
B4 Gross Total Income (B1 + B2 + B3) B4 (-)
PART C - DEDUCTIONS AND TAXABLE TOTAL INCOME
C1 C1 80C C2 80CCC C3 80CCD

C4 80CCF C5 80D C6 80DD

to C7 80DDB C8 80E C9 80G

C10 80GG C11 80GGA C12 80GGC

C13
C13 80U
C14 Total Deductions ( Add items C1 to C13 ) C14
C15 Taxable Total Income( B4 - C14 ) C15 (-)
FOR OFFICIAL USE ONLY

SEAL, DATE AND SIGNATURE OF

STAMP RECEIPT NO. HERE
RECEIVING OFFICIAL
 PERMANENT ACCOUNT NUMBER 2012-13 ITR-1, PAGE 2

PART D—TAX COMPUTATION AND TAX STATUS

D1 Tax Payable On Total Income(C15) Secondary & Higher Education Cess TOTAL TAX AND CESS ( D1+ D2 )
to
D3 D1 D2 D3
D4 Relief u/s 89 Relief u/s 90/91 Balance Tax After Relief ( D3-D4-D5)
to
D6 D4 D5 D6
D7 Total Interest u/s 234A/234B/234C Total Tax and Interest (D6+D7) Total Advance Tax Paid
to
D9 D7 D8 D9
D10 Total Self Assessment Tax Paid Total TDS Claimed Total Prepaid Taxes ( D9+D10+D11)
to
D12 D10 D11 D12
D13 Tax Payable ( D8-D12, If D8>D12) Refund ( D12—D8, If D12 >D8 )
to
D14 D13 D14
Bank Account Details ( Mandatory in all cases irrespective of refund due or not)
9D15 ACCOUNT No. 9D16 MICR CODE

9D17 Type of account: 9 ; Current 9 ; Savings 9D18 Fill only one: Refund by 9 ; cheque or 9 ; deposited directly into your bank account

9D19 Exempt income only for reporting purposes

VERIFICATION
I, 9 son/ daughter of 9 solemnly declare that to the best of my knowledge
and belief, the information given in the return is correct and complete and that the amount of total income and other particulars shown therein are truly stated and are in
accordance with the provisions of the Income-tax Act, 1961, in respect of income chargeable to Income-tax for the previous year relevant to the Assessment Year 2012-13.

Place D D MM Y Y Y Y SIGN HERE è

If the return has been prepared by a Tax Return Preparer (TRP) give further details as below
Name of the TRP TRP PIN [ 10 Digit ] Amount to be paid to TRP TRP Signature
9 9

Sch IT - DETAILS OF ADVANCE TAX AND SELF ASSESSMENT TAX PAYMENTS

BSR CODE(col.i) DATE OF DEPOSIT(col.ii) CHALLAN NO(col.iii) TAX PAID(col.iv)
R1 9 9
D D MM Y Y Y Y 9 9

R2 9 9
D D MM Y Y Y Y 9 9

R3 9 9
D D MM Y Y Y Y 9 9

R4 9 9
D D MM Y Y Y Y 9 9

R5 9 9
D D MM Y Y Y Y 9 9

NOTEð (1) Enter the totals of Advance Tax and Self Assessment Tax in D9 and D10 (2) Continue in Supplementary Schedule IT if you cannot fill within Sch IT
Sch TDS1 - DETAILS OF TAX DEDUCTED AT SOURCE FROM SALARY [As per Form 16 issued by Employer(s)]
TAN(col.i) NAME OF THE EMPLOYER(col.ii) INCOME UNDER SALARY(col.iii) TAX DEDUCTED(col.iv)
S1 9 9 9 9

S2 9 9 9 9

S3 9 9 9 9

NOTEð (1) Enter the total of column (iv) of Sch TDS1 and column (vi)of Sch TDS2 in D11 (2) Continue in Supplementary Schedule TDS1 if you cannot fill within Sch TDS1

Sch TDS2 - DETAILS OF TAX DEDUCTED AT SOURCE FROM INCOME OTHER THAN SALARY [As per Form 16A issued by Deductor(s)]
TAN(col.i) NAME OF THE DEDUCTOR (col.ii) UNIQUE TDS CER. NO(col.iii) DEDUCTED YEAR(col.iv) TAX DEDUCTED(col.v) AMT OUT OF(v) CLAIMED THIS YR(col vi)
T1 9 9 9 9
Y Y Y Y 9 9

T2 9 9 9 9
Y Y Y Y 9 9

T3 9 9 9 9
Y Y Y Y 9 9

T4 9 9 9 9
Y Y Y Y 9 9

NOTEð (1) Enter the total of column (iv) of Sch TDS1 and column (vi)of Sch TDS2 in D11 (2) Continue in Supplementary Schedule TDS2 if you cannot fill within Sch TDS2
 PERMANENT ACCOUNT NUMBER
AY 2012-13
FIRST NAME MIDDLE NAME LAST NAME

SUPPLEMENTARY SCHEDULE TDS 1(To be used only after exhausting items S1-S3 of Schedule TDS1 in main form etc)
TAN(col.i) NAME OF THE EMPLOYER(col.ii) INCOME UNDER SALARY(col.iii) TAX DEDUCTED(col.iv)
S4 9 9 9 9

S5 9 9 9 9

S6 9 9 9 9

S7 9 9 9 9

S8 9 9 9 9

S9 9 9 9 9

S10 9 9 9 9

S11 9 9 9 9

S12 9 9 9 9

S13 9 9 9 9

S14 9 9 9 9

S15 9 9 9 9

S16 9 9 9 9

S17 9 9 9 9

S18 9 9 9 9

S19 9 9 9 9

S20 9 9 9 9

S21 9 9 9 9

S22 9 9 9 9

S23 9 9 9 9

S24 9 9 9 9

S25 9 9 9 9

S26 9 9 9 9

S27 9 9 9 9

S28 9 9 9 9

S29 9 9 9 9

S30 9 9 9 9
 PERMANENT ACCOUNT NUMBER
AY 2012-13
FIRST NAME MIDDLE NAME LAST NAME

SUPPLEMENTARY SCHEDULE TDS 2 (To be used only after exhausting items T1-T4 of Schedule TDS2 in main form etc)
TAN(col.i) NAME OF THE DEDUCTOR (col.ii) UNIQUE TDS CER. NO(col.iii) DEDUCTED YEAR(col.iv) TAX DEDUCTED(col.v) AMT OUT OF(v) CLAIMED THIS YR(col vi)
T5 9 9 9 9
YYYY 9 9

T6 9 9 9 9
YYYY 9 9

T7 9 9 9 9
YYYY 9 9

T8 9 9 9 9
YYYY 9 9

T9 9 9 9 9
YYYY 9 9

T10 9 9 9 9
YYYY 9 9

T11 9 9 9 9
YYYY 9 9

T12 9 9 9 9
YYYY 9 9

T13 9 9 9 9
YYYY 9 9

T14 9 9 9 9
YYYY 9 9

T15 9 9 9 9
YYYY 9 9

T16 9 9 9 9
YYYY 9 9

T17 9 9 9 9
YYYY 9 9

T18 9 9 9 9
YYYY 9 9

T19 9 9 9 9
YYYY 9 9

T20 9 9 9 9
YYYY 9 9

T21 9 9 9 9
YYYY 9 9

T22 9 9 9 9
YYYY 9 9

T23 9 9 9 9
YYYY 9 9

T24 9 9 9 9
YYYY 9 9

T25 9 9 9 9
YYYY 9 9

T26 9 9 9 9
YYYY 9 9

T27 9 9 9 9
YYYY 9 9

T28 9 9 9 9
YYYY 9 9

T29 9 9 9 9
YYYY 9 9

T30 9 9 9 9
YYYY 9 9

T31 9 9 9 9
YYYY 9 9
 PERMANENT ACCOUNT NUMBER
AY 2012-13
FIRST NAME MIDDLE NAME LAST NAME

SUPPLEMENTARY SCHEDULE IT(To be used only after exhausting items R1-R5 of Schedule IT in main form etc)
BSR CODE(col.i) DATE OF DEPOSIT(col.ii) CHALLAN NO(col.iii) TAX PAID(col.iv)
R6 9 9
D D MM Y Y Y Y 9 9

R7 9 9
D D MM Y Y Y Y 9 9

R8 9 9
D D MM Y Y Y Y 9 9

R9 9 9
D D MM Y Y Y Y 9 9

R10 9 9
D D MM Y Y Y Y 9 9

R11 9 9
D D MM Y Y Y Y 9 9

R12 9 9
D D MM Y Y Y Y 9 9

R13 9 9
D D MM Y Y Y Y 9 9

R14 9 9
D D MM Y Y Y Y 9 9

R15 9 9
D D MM Y Y Y Y 9 9

R16 9 9
D D MM Y Y Y Y 9 9

R17 9 9
D D MM Y Y Y Y 9 9

R18 9 9
D D MM Y Y Y Y 9 9

R19 9 9
D D MM Y Y Y Y 9 9

R20 9 9
D D MM Y Y Y Y 9 9

R21 9 9
D D MM Y Y Y Y 9 9

R22 9 9
D D MM Y Y Y Y 9 9

R23 9 9
D D MM Y Y Y Y 9 9

R24 9 9
D D MM Y Y Y Y 9 9

R25 9 9
D D MM Y Y Y Y 9 9

R26 9 9
D D MM Y Y Y Y 9 9

R27 9 9
D D MM Y Y Y Y 9 9

R28 9 9
D D MM Y Y Y Y 9 9

R29 9 9
D D MM Y Y Y Y 9 9

R30 9 9
D D MM Y Y Y Y 9 9

R31 9 9
D D MM Y Y Y Y 9 9

R32 9 9
D D MM Y Y Y Y 9 9